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## London School of Hygiene & Tropical Medicine

Skip to 0 minutes and 13 secondsDR DOROTHY SHAW: We started this course on maternal health by taking a look at the epidemiology of maternal mortality and morbidity in the last step. In this step, we look at important changes in the past 25 years, and what maternal health looks like today. Maternal health is closely linked to global fertility patterns, as you can see in the first slide. Globally, fertility is declining, but the population age structure remains young, and unmet need for contraception is high. The percentage of women with an unmet need for contraception has declined globally since 1990, but remains high, particularly in Africa.

Skip to 0 minutes and 54 secondsGlobally, the number of women with an unmet need for family planning is projected to change little, from $142 million in 2015 to$143 million in 2030. This means that the projected number of pregnancies is high. Life expectancy is also increasing, and the roles of women are changing. This graph shows the increasing proportion of births occurring at older ages. In high income countries, many women are delaying childbearing until after having completed higher education and finding permanent work. In some countries-- such as Spain, Germany, and Japan-- total fertility rates are very low at 1.3 to 1.4 births per woman. Demographic change and epidemiological change are closely linked.

Skip to 1 minute and 45 secondsThe epidemiological transition describes the shift in patterns of disease from acute communicable episodes towards chronic and non-communicable conditions. A variant of the epidemiological transition is the obstetric transition where there is a shift from high to low fertility and maternal mortality, and from a high to a low proportion of deaths due to direct obstetric causes. As more women have births at older ages, patterns of mortality cause a shift towards a greater proportion of deaths due to indirect causes. Alcohol consumption and smoking during pregnancy are both associated with adverse outcomes for newborns. Alcohol intake during pregnancy varies cross-nationally. It is highest in Europe, followed by the Americas. There are also emerging concerns such as Zika virus.

Skip to 2 minutes and 41 secondsZika spreads primarily through infected mosquitoes and is associated with microcephaly and other fetal brain defects in babies. Smoking prevalences, as well as trends in tobacco use, vary cross-nationally. Although global prevalence of tobacco smoking is expected to decline by 2025, in Africa and the eastern Mediterranean, it's expected to increase. Data on smoking at the start of or during pregnancy is not available for all countries, but is between 5.5% and 23% for selected high income countries. Smoking during pregnancy carries risks, including miscarriage, low birth weight babies, and premature birth. Demographic and epidemiological changes don't take place in a vacuum, but in the context of social, economic, and environmental change.

Skip to 3 minutes and 38 secondsNow, we'll look at social, political, economic, and environmental changes in relation to maternal health. The world's population is becoming increasingly urban, with more than 50% living in urban areas. This is expected to increase to two-thirds by 2050. Alongside increasing wealth, this is contributing to a higher prevalence of obesity and diabetes. Aspirations to modernity often lead to smaller families and greater investment in fewer children. Expectations of care are also changing, and as families have fewer children, expectations for healthy birth outcomes increase. Finally, the political environment also matters. A good example of this is shown in different political parties' positions on abortion in the United States (US).

Skip to 4 minutes and 33 secondsSimilarly, this map shows how changes in abortion restrictions in US states mean that a far greater proportion of women in 2013 than 2010, lived in states considered hostile to abortion. These restrictions, which make it more difficult for women to obtain abortion information, counselling, and services, have a direct impact on their health and well-being. Economic changes are also important, particularly because poverty and inequality disproportionately affect women. Women represent an increasing proportion of those in education and the workforce, however, women are still paid less, have less security, and are less likely to be unionised. Furthermore, women are still undertaking most of the domestic work, too. There is a synergy between poverty and gender inequality.

Skip to 5 minutes and 30 secondsFor example, households headed by women are less likely to own farmland than households headed by men. And poor girls are less likely to attend school than poor boys. And what about national economies? Rapid economic growth in low- and middle-income countries means that there is potential for domestic investment in health, including maternal health. We will discuss this further in week three of the course. Finally, these changes take place in the context of environmental change, including climate change, environmental degradation, and natural disasters. These environmental changes, which affect human health and well-being, in a broad sense, have a disproportionate effect on the health of women and girls.

Skip to 6 minutes and 18 secondsFor example, there are greater opportunity costs to women and girls of increased time spent collecting fuel and water. And they bear an unequal burden of cooking responsibilities, with smoke from biofuel stoves associated with adverse pregnancy outcomes. In conclusion, women's health is driven by multiple interlinked determinants, or drivers, and is disproportionately impacted by poverty and inequality. Health systems in low- and middle-income countries will need to plan for high numbers of pregnancies due to a young and growing population with unmet need for contraception. This may also apply in some high-income countries, such as the US, if access to contraception and abortion becomes further restricted.

Skip to 7 minutes and 8 secondsEducation of women benefits the workforce and economy at all levels and these changing expectations of outcomes for pregnancy and health. Evolving climate change, epidemics, and increasing levels of diabetes and obesity raise new health concerns, especially for women, that require a gender sensitive lens for response and planning.

# What are the drivers of change?

What is driving the changing epidemiology of global maternal health?

In this step Dr Dorothy Shaw (BC Women’s Hospital) explores the maternal health drivers including demographic changes in patterns of child bearing, changes in epidemiologic exposures and behaviours. The step concludes by explaining how these changes take place in contexts of social, political and environmental change.